Provider Demographics
NPI:1316239197
Name:REYNOLDS, BLAKE MATTHEW (SOIDC)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:MATTHEW
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC BOX 20116
Mailing Address - Street 2:2D MARINE SPECIAL OPERATIONS BATTALION
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0116
Mailing Address - Country:US
Mailing Address - Phone:910-440-7704
Mailing Address - Fax:
Practice Address - Street 1:2D MSOB, BLDG. A-66
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0183
Practice Address - Country:US
Practice Address - Phone:910-440-7704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman